Last week, I had a patient who came from dialysis with bleeding from his AV graft. He had completed his entire dialysis session without any problems, and when they removed the needle from his graft, he started having bleeding. Pressure was applied, but to no avail. By the time he got to us, intermittent pressure had been applied for an hour without stoppage of the bleeding. I was going through some different treatment options, and thought it would make a good blog post. For clarification, this guy was having definite arterial bleeding. Not shooting-across-the-room type of arterial, but pulsatile with a significant amount of blood loss.
What I ended up doing is placing two figure of eight stitches. Here is a very cool YouTube showing this procedure: https://www.youtube.com/watch?v=toFiGSfesZk
You should definitely know how to do this. I also talked with the senior vascular surgery resident. He said he likes to take a piece of gelfoam, place it over the spot that’s bleeding, hold gentle pressure for 10 minutes (not hard pressure; that could occlude the graft and cause it to clot off = bad). He assured me that this works even for arterial bleeding.
A quick search yielded these recommendations from ACEP: https://www.acep.org/Clinical—Practice-Management/Focus-On–Dialysis-Access-Emergencies/
Note that the authors are former SGH residents and Dr Barton! Very cool!
If the patient is not having arterial bleeding and is more just oozing, I like DDAVP. You also have to consider protamine if the patient is coming from dialysis because they do get heparin during dialysis.
Take home points: consider throwing in some figure-of-eight sutures, using gelfoam, or possibly using medication (DDAVP, protamine) to stop the bleeding from an AV graft/fistula.
What other bleeding problem is DDAVP used in? How does it work? Why does it help dialysis patients?
The suture you want is Hemoseal HS7 5-0 prolene
I was also wondering about the use of tranexamic acid to stop bleeding, any thoughts?
Hi Sharmin, I did a VERY quick lit search, but it seems that the use of TXA for this is very limited at the point and it’s use it not yet recommended.
1. To answer your question about bleeding: it can be used in VWF deficiency and hemophilia A. It causes release of VWF, which results in an increase in Factor VIII as well. As far as how it works in renal patient, I presume they have lost some of these factors from bleeding, so the release from the endothelium replaces those. VWF interacts with platelets and promotes coagulation. I’m sure there are other things I’m missing too.
2. Usually decreased UO is a contraindication for DDAVP. Is this allowed because they are on dialysis? Does it matter whether the patient is anuric or not?
Most of the needles are cutting needles (to be perfectly honest, this is what I used on my patient…I wasn’t aware that I was supposed to use non-cutting needles), but I will check if there are non-cutting needles during my shift tomorrow.
Do we have cutting or non-cutting suture needles in our ED?